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MNT FOR
OVERWEIGHT AND OBESITY
Inggita Kusumastuty
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WEIGHT IMBALANCE : OBESITY & OVERWEIGHT
Overweight is a state in which exceeds a standard based on height
Obesity is a condition of excessive fatness, either generalized or
localized.
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Obesitas adalah hasil dari ketidakseimbangan antara makanan yang
dikonsumsi dengan aktivitas fisik
terdapat penimbunan lemak yang berlebihan daripada yang diperlukan untuk
fungsi tubuh, sebagai akibat mengkonsumsi makanan yang jauh melebihi
kebutuhannya
(Krauses Food 12
th
Edition)
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ETIOLOGY
Hereditas atau keturunan
Lingkungan
Psikologi
Fisiologi
(Midasari, 2007); (Krauses Food 12
th
Edition)
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Marketing to Children
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MANIPULATING CHILDRENS BEHAVIOUR
Food promotion
Can confuse nutritional knowledge e.g whether fruit is in product
Changes food prefences
Changes purchasing behaviour
Influences choice and consumption by brand
Alter balance of catagories of food eaten
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UK Food Standards Agency, 25
th
September 2003
CHANGING DIETARY HABITS
Increased intake of caloric sweeteners & edible oil
Increased intake of processed foods, refined carbohydrates & salty
high fat snacks
Reduced intake of fruits and vegetables
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From Traditional food to Modern Meals
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PORTION SIZE
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From Traditional to Modern Snacking
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From Traditional Food Marketing to Modern
Food Supermarkets
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DECREASED PHYSICAL ACTIVITY
Excess TV; computer, & play station time
Children are home alone (dual income parents)
Decreased physical activity at school & at home
Transportation by car or school bus
Neighborhood safety
Few public parks, sidewalks, swimming pools ..etc
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From Traditional to Modern Leisure
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Klasifikasi dan risiko Penyakit
Penyerta berdasar WHO:
Klasifikasi dan risiko Penyakit
Penyerta untuk orang ASIA:
(Lestiani, 2011)
KLASIFIKASI
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TEBAL LIPATAN KULIT TRISEP
Obesitas umumnya menyebabkan akumulasi lemak pada daerah subkutan dan
jaringan lainnya. Cara yang digunakan untuk mengukur lemak subkutan di
lengan atas, salah satunya dengan mengukur Tebal Lipatan Kulit Trisep
Kategori Interpretasi
>85 percentil obesitas
>95 percentil superobesitas
(Rahmawati, 2009) 15
Waist Circumference untuk mendeteksi obesitas melalui akumulasi lemak
visceral tubuh
Cutt off ASIA:
Laki-laki : >90 cm
Perempuan : >80 cm
(Gibson, 2005)
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BEHNKES THEORITICAL BODY COMPOSITION MODEL FOR A MAN
AND WOMAN WITH HEALTHY PERCENTAGE BODY-FAT RANGES
Males
Total fat 8%-24%
Storage fat 5%-21%
Essential fat 3%
Muscle 44.8%
Bone 14.9%
Remainder 16.3-32.3%
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Females
Total fat 21%-35%
Storage fat 9% - 23%
Essential fat 12%
Muscle 38%
Bone 12%
Remainder 15-29%
BODY FATNESS
(DEURENBERG AND DEURENBERG-YAP, 2003)
% body fat = (1,2 x BMI) + (0,23 x age in yrs)- (10,8x G)-5,4
G =1 for male, G=0 for female
For example if BMI=28, age 21and G=female
%body fat = (1,2x28)+(0,23x21)-(10,8x0)-5,4
= 33,6+4,83-0-5,4
= 33%
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NOTE:
A body fat percentage of 20% to 25% or more in a male and 25%
to 32% or more in female is ussualy considered to be excessive and
associated with the metabolic and health risks of obesity
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PATHOPHYSIOLOGY
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FAT CELL DEVELOPMENT
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FAT CELL METABOLISM
Enzim LPL
Promote
fat storage
adiposa
Muscle
cells
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Gender specific hormones (estrogen dan testosteron)
regulates
LPL Activity
Women :
Fat Cells in the breast
Fat cells in the hips
Fat cells in the thighs
Men :
Fat cells in the abdomen
Produce abundant LPL Produce abundant LPL
Tipe Obesity :
Men = Central Obesity
Women = Lower body fat around hip and thigh
OBESITY PROMOTE HEALTH
PROBLEM
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-cell pankreas
Insulin Release
Fosforilasi IRS 1 & IRS 2
Signal Insulin
Glut-4 ke
membran sel
Glukosa
masuk sel
Diet Lemak
Fat cell
Sitokain
Serin
Obesitas
Adiponektin
Glukosa serum
Resistensi insulin
Tyr fosforilasi
DIET TINGGI LEMAK MENYEBABKAN RESISTENSI INSULIN
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MEKANISME OBESITAS MENYEBABKAN DISLIPIDEMIA (BARBARA, ET AL. 2003)
Obesitas
Kolesterol
Insulin Resisten
Aktivitas LPL
Plasma TG (TG yang
ada dalam VLDL dan
Kilomikron )
clearence VLDL
Glukosa Hepatic

Pengambilan
Glukosa otot
FFA Gangguan
aksi LDL-R
FFAdan Glukosa Hepar
Produksi
VLDL
VLDL Plasma
Fasting dan PP
TRL
small dense LDL HDL
clearence VLDL
1
2
3
4
*LPL : Lipoprotein Lipase
LDL-R : LDL Receptor
TRL : Triglyseride Rich Lipoprotein
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MEKANISME INSULIN RESISTEN MENYEBABKAN DIABETES
MELLITUS TIPE 2
(Mechanisms linking obesity to insulin resistance and type 2 Diabetes.
Steven E. Kahn, Rebecca L. Hull and Kristina M. Utzschneider. Nature 444,
840-846(14 December 2006) 27 28
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OBESITY DIABETES CHD
HYPERTENSION
+
+
Dietary change
BULK,
e.g. vegetables,
tubers, cereals
Phytoestrogens
bioactivate molecules
Folate, B
6
Homocysteinaemi
a
Thrombosi
s

Sex hormone
changes
CANCERS: breast, endometrium
Trans fatty
acids
n-3 fatty acids
Saturated fats

Atherosclerosis
Antioxidant
s
Total Fat
The interlinking of physical inactivity and dietary effects on obesity and the
progression of disease with industrialisation
Energy
density: fat
& refined
CHOs
+
+
-
-
-
Physical inactivity
+ + +
+
+
+ +
+
+
-
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MANAGEMENT OF OBESITY IN ADULT
Medical Management
Lifestyle modification (increase exercise)
Psycological support
Drugs
Surgery
Nutritional Management
Food choice changes
Nutrition education
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OBESITY TREATMENT PYRAMID
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DECIDING ON TREATMENT
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SURGARY
Weight loss surgery is an option for carefully selected patients with clinically
severe obesity (BMI 40 or 35 with comorbid conditions) when less invasive
methods of weight loss have failed and the patient is at high risk for obesity-
associated morbidity or mortality
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MEDICATION
Weight loss drugs approved by the FDA for long-term use may be useful as an
adjunct to diet and physical activity for patients with a BMI of 30 with no
concomitant obesity-related risk factors or diseases, and for patients with a BMI
of 27 with concomitant obesity-related risk factors or diseases
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PHYSICAL ACTIVITY
Initially, moderate levels of physical activity for 30 to 45
minutes, 3 to 5 days per week should be encouraged.
All adults should set a long-term goal to accumulate at
least 30 minutes or more of moderate-intensity physical
activity on most, and preferably all, days of the week
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JENIS OR YANG AMAN BAGI PASIEN
OBESE
1. Berjalan kaki (30 menit/hari, 5-6 x/minggu)
2. Jalan cepat (12 jam membakar 3500 kkal)
3. Berjalan diselingi jogging ringan
4. Senam aerobik low impact
5. Berenang dengan jarak agak jauh
6. Berjalan kaki di kolam renang setinggi pinggang.
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TIPE OLAHRAGA UNTUK OBESITAS
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JENIS DURASI INTENSITAS
Voli
45-60 menit Intensitas Rendah,
Durasi Tinggi
Intensitas Tinggi,
Durasi Rendah
Berjalan 1 mil
35 menit
Shooting basketball
30 menit
Bersepeda 5 mil
30 menit
Berenang
20 menit
Bermain basket
15-20 menit
Lompat tali
15 menit
Berlari mil
15 menit
SOME DIETS FOR OBESITY
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SOME DIETS, NOT WORKS
Low Calorie Diets: (-) 500 to 1000 Kcal daily requirements
Meal Replacements: 200-300 Kcal High satiety (Protein
+ fibre)
Very Low Calorie Diets:200-800 calories daily
(rich protein 0.8-1.5g/ kgIBW) 12 to 16 weeks
BMI 27 to 30Rapid wt loss
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WHY DIET DOESNT WORK?
1. Regaining Wt among dieters is the norm not the exception.
Lower BMR easier to put on weight (J Nutr 2005 Jun;
135(6):1347-52)
2. No one can live on a Diet forever
3. We are in daily contact with food
4. Need lifestyle strategies
5. Food behaviour modification
6. Personal responsibility
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EFEKTIFITAS VLCD DALAM PENGATURAN BERAT BADAN
BERDASARKAN PENELITIAN TENTANG EFEKTIFITAS VLCD DI MALAYSIA YANG DILAKUKAN
OLEH ISMAIL NOOR DAN KHOR POH KIM ( 2002) SELAMA 6 MINGGU MASA ST UDI,
MENYEBUTKAN BAHWA:
Pria Wanita
Total weight loss 4,5 kg 3,4 kg
Waist circumference loss 8,0 cm 8,0 cm
Hip circumference loss 5,5 cm 6,0 cm
Body fat reduction 3,6 cm 2,3 cm
BMI reduction 1,5 kg/m
2
1,4 kg/m
2
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EFEK NEGATIF VLCD
(Nutrition Practise:50;
Krauss Food & Nutrition
Theraphy:548)
menyebabkan defisiensi
beberapa zat gizi dan
elektrolit
Kehilangan massa otot
Pembentukan gallstones
(Handbook of nutrition &
food:899; Krauss Food &
Nutrition Theraphy:548)
Orthostatic hypotension
Gout (ketones bersaing
dengan uric acid untuk
diekskresi)
(krauses)
Fatigue / keletihan
Light-headedness /
dizziness
Dapat diatasi dengan
merubah posisi tubuh
secepatnya, hindari
mandi sauna, minum 1.5-
2 L per hari.
Kulit kering
Rambut kemerah-
merahan karena
kekurangan beberapa
mineral seperti Zn
Menstrusi terganggu
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NUTRITION INTERVENTION Low-calorie diets are the closest to most peoples
general eating patterns and present the fewest
risks for the patient
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INTERVENTION OBJECTIVES
Reduce body weight
Maintain a lower body weight over the long time
Prevent futher weight gain
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The National Institutes of Health suggests a reduction of 10%
in body weight as an initial goal.
A weight loss of 5%10% has been shown to reduce the risk
of heart disease and stroke.
CMAJ January 3, 2006 174(1)
(Nutrition and Diagnosis Related Care, 2008)
NUTRITION INTERVENTION FOR OBESITY
Carbohydrate : 35 50% TEE
Fat : 25 35% TEE
Protein : 25 35% TEE
Low glicemic load
Fiber : 25 35 g/ day
Adaquate fluid
Low salt
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Nutrition and Diagnosis Related Care, 2008
NUTRITION INTERVENTION
What will work long term
Wt loss 5-10%/wk
Wt loss 0.5-1.5 kg/wk
Some long term energy restriction
is inevitable
1200 to 1800 Kcal
Regular Physical Activity
Healthy eating
Low fat (foods and cooking)
High carbohydrates (low refined)
High protein
High fiber
Indulge in low energy dense foods
(CMAJ. 2007 April 10; 176(8): S1
S13.)
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ESTIMATING ENERGY NEEDS FOR OBESE
Using ideal body weight (IBW) when calculating energy
requirements in the obese population does not allow for increased
lean body mass (LBM) needed for structural support of the extra
adipose tissue
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Cunningham developed a formula to estimate energy
requirements of the obese, often referred to as Adjusted
Body-Weight for Obesity
equations like the Harris Benedict equation
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ESTIMATING ENERGY NEEDS FOR OBESE
Adjustment Body Weight for Obesity:
[(ABW-IBW )x 0.25 + IBW]= weight to be used for
calculating REE
ABW= actual body weight
IBW=ideal body weight
0.25 represents the percentage of excess body weight that is
metabolically active
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PERHITUNGAN ENERGI
Krauses Food 12
th
Edition
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SOME INTERVENTIONS STRATEGIES THAT COULD BE CONSIDERED
FOR PREVENTION OF CHILDHOOD OBESITY
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Nutrition Journal 2005, 4:24
NUTRITION INTERVENTION IN CHILDHOOD OBESITY
The two most popular diets followed by adults, the
low-carbohydrate diet and the low-fat/low-calorie
diet, have not yet been evaluated extensively for
safety and efficacy in children
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Source : Philippas, G. Niki & Lo, W. Clifford. Nutrition in Clinical Care, Volume 8, Number 2, 2005 77
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NUTRITION INTERVENTION IN CHILDHOOD OBESITY
Energy according age, activity, likelihood growth
Protein : 10 35% TEE
Fat : 25 40% TEE
Carbohydrate : 45 60%TEE
Decrease the use of sweets as snack food or dessert
Control between meal-snack
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Krauses Food & Nutrition Therapy 12 edition
Nutrition and Diagnosis Related Care, 2008
STRATEGI MODIFIKASI GAYA HIDUP
(KRAUSES FOOD 12
TH
EDITION)
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FOOD WEIGHT LOSS TIPS
Establish regular meals times
Read food labels when purchasing food items
Make substitution in diet to cut calories
Identify guilty pleasure such as ice cream
Pre-portion serving to control the amount
Control calories when dining out
Pre-plan meals & snacks, and make a certain to have the food on
hand
Avoid places & situation that trigger eating
Try substituting other activities for eating
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THE MOST USEFUL PROGRAM
COMPONENTS :
food-label reading
cooking sessions
learning new and different physical exercises, including home-based
options.
Self-management techniques helpful (problem solving)
The use of a group setting and supportive 'peer' leaders were
found to be supportive.
More frequent clinical assessment was suggested for future
programs.
(International Journal of Behavioral Nutrition and Physical Activity 2008,
5:53)
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THANK YOU
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